Luis E. Raez

Novel therapeutic strategies for patients with NSCLC that do not respond to treatment with EGFR inhibitors

INTRODUCTIONnTreatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) yields tumour responses in non-small cell lung cancer (NSCLC) patients harbouring activating EGFR mutations. However, even in long-lasting responses, resistance to EGFR TKIs invariably occurs.nnnAREAS COVEREDnThis review examines resistance mechanisms to EGFR TKI treatment, which mainly arise from secondary EGFR mutations. Other resistance-inducing processes include mesenchymal-epithelial transition factor (MET) amplification, epithelial-mesenchymal transformation, phenotypic change from NSCLC to small-cell lung carcinoma, and modifications in parallel signalling pathways. Current therapeutic strategies to overcome these EGFR TKI resistance mechanisms focus on the inhibition or blocking of multiple members of the ErbB family. Several molecules which target multiple ErbB receptors are being investigated in NSCLC and other indications including afatinib, an ErbB Family Blocker, as well as dacomitinib and lapatinib. Novel, non-quinazoline, EGFR inhibitors, that also target EGFR activating and resistance (T790M) mutations, are currently under clinical development. Other therapeutic strategies include inhibition of parallel and downstream pathways, using agents which target heat shock protein (HSP)90 or poly (ADP-ribose) polymerase in addition to mammalian target of rapamycin (mTOR), monoclonal antibodies against the insulin-like growth factor-1 receptor, and fulvestrant-mediated oestrogen receptor regulation.nnnCONCLUSIONnImproved understanding of mechanisms underlying resistance to EGFR TKIs emphasises the importance of a genotype-guided approach to therapy. Elucidation of resistance mechanisms is indeed crucial to target innovative therapeutic approaches and to improve the efficacy of anticancer regimes in NSCLC.

Immunotherapeutic Agents in Non-small-cell Lung Cancer Finally Coming to the Front Lines

Non-small-cell lung cancer usually carries a dismal prognosis. Novel treatment approaches are clearly warranted. Immunotherapy has emerged as a promising area of research developing agents that manipulate the immune system to induce antitumor responses while avoiding major toxicity. New vaccines and checkpoint inhibitors are currently undergoing investigation in phase II and phase III clinical trials. In advanced non-small-cell lung cancer (NSCLC), belagenpumatucel-L, an allogeneic cell vaccine directed against transforming growth factor β in the tumor microenvironment, knocks down the immune suppression caused by the tumor and has demonstrated a dose- and time-dependent efficacy in some subgroups of patients. L-BLP25 and TG4010 are both antigenic vaccines that target mucin 1, whose encoding proto-oncogene is commonly mutated in solid tumors. The L-BLP25 vaccine achieved a significant improvement in overall survival in the subgroup of patients with stage IIIB NSCLC treated with chemoradiotherapy. TG4010 vaccination resulted in better progression-free survival when added to cisplatin–gemcitabine chemotherapy. These results are being addressed in the currently ongoing phase III TIME trial. In the adjuvant setting, MAGE-A3, an antigen-based vaccine, showed promising results in melanoma-associated antigen A3 positive lung cancer patients who underwent resection in the phase II study; however, no improvement in progression-free survival was observed in the phase III MAGRIT study. CIMAVax is a recombinant human epidermal growth factor (EGF) vaccine that induces anti-EGF antibody production and prevents EGF from binding to its receptor. It has improved overall survival in patients with advanced NSCLC who achieve seroconversion. Ipilimumab, an immune checkpoint inhibitor that targets cytotoxic T-lymphocyte antigen 4, demonstrated improved progression-free survival in advanced NSCLC patients who received the drug after chemotherapy in a phased regimen. Finally, anti-programmed death receptor 1 agents have achieved durable response rates in phase I studies. This review gives an overview of the current data and the most promissory immunotherapeutic agents for NSCLC.

The potential of neurotrophic tyrosine kinase (NTRK) inhibitors for treating lung cancer

ABSTRACT Introduction: Molecular alterations in neurotrophic tyrosine kinase (NTRK) genes have been identified in several solid tumors including lung cancer. Pre-clinical and clinical evidence suggested their potential role as oncogenic drivers and predictive biomarkers for targeted inhibition, leading to the clinical development of a new class of compounds blocking the NTRK molecular pathway, which are currently undner early clinical investigation. Area covered: This review describes the biology of the NTRK pathway and its molecular alterations in lung cancer. It focuses on the pre-clinical and clinical development of emerging NTRK inhibitors, which have shown very promising activity in early phase I studies. Expert opinion: Among the several NTRK-inhibitors, entrectinib and LOXO-101 are those in more advanced stage of clinical development. Both agents have shown encouraging activity along with a tolerable safety profile in patients with different solid tumors harboring NTRK-fusions, emerging as new promising therapeutic options for molecularly selected patients with advanced Trk-driven lung cancers. Results from ongoing phase II basket trials are eagerly awaited.

Entinostat (SNDX-275) for the treatment of non-small cell lung cancer

Introduction: Epigenetic aberrations play an important role in lung carcinogenesis. Chromatin deacetylation is a fundamental mechanism of gene silencing. Histone deacetylase (HDAC) inhibitors are an emerging class of antineoplastic agents that enable the accessibility of DNA to transcription factors, therefore promoting gene expression. Entinostat is a selective HDAC inhibitor that has shown anti-neoplastic activity and tolerability in hematologic and solid tumors, including lung cancer. Areas covered: This article summarizes the pharmacokinetics, pharmacodynamics, mechanisms of action, safety, tolerability, pre-clinical studies and clinical trials of the HDAC inhibitor entinostat, as a novel promissory agent for the treatment of NSCLC. Expert opinion: The field of targeted therapy has increased in lung cancer. However, even now with the current FDA-approved agents, < 15% of patients benefit from these interventions and we are still far from curing lung cancer. New targets are needed. Either in combination with cytotoxic drugs, epigenetic therapy or other molecular targeted drugs, entinostat represents a new potential agent for the treatment of non-small cell carcinomas. However, the preliminary safety and efficacy results from several clinical trials still need to be validated in large Phase III trials.

Epidermal growth factor vaccine in non-small-cell lung cancer

After many years of uncertainty regarding the role of immunotherapy in cancer, we finally have vaccines approved for the treatment of some malignancies (e.g., prostate cancer and melanoma). In non-small-cell lung cancer, several vaccines are being studied in randomized Phase III clinical trials due to their promising results seen in the clinic, such as BLP-25 and melanoma-associated antigen A3. Traditionally, non-small-cell lung cancer has not been considered a good target for immunotherapy due to lack of immunogenicity and the strong presence of regulatory T cells, which do not allow an adequate immune response in the host. EGF vaccination is a novel area of immunotherapy for this disease. Thus far, there has been success in generating immune and clinical responses with this vaccine in several clinical trials, and we will review in depth the efficacy and toxicity of this novel agent.

Challenges in Facing the Lung Cancer Epidemic and Treating Advanced Disease in Latin America

Micro‐Abstract: Latin America will soon be facing a lung cancer epidemic. The region is not prepared to deal with the amount of patients and the resources needed to give the patients proper state of the art molecular diagnosis and access to targeted therapies. In this paper, we review the current management of lung cancer in Latin America from the clinicians perspective. Abstract Lung cancer, the deadliest cancer worldwide, is of particular concern in Latin America. The rising incidence poses a myriad of challenges for the region, which struggles with limited resources to meet the health care needs of its low‐ and middle‐income populations. In this environment, we are concerned that governments are relatively unaware of the pressing need to implement effective strategies for screening, diagnosis, and treatment of lung cancer. The region has also been slow in adopting molecularly‐based therapies in the treatment of advanced disease: testing for epidermal growth factor receptor mutations and anaplastic lymphoma kinase rearrangements are not routine, and access to targeted agents such as monoclonal antibodies and tyrosine kinase inhibitors is problematic. In this paper, we review the current situation in the management of lung cancer in Latin America, hoping that this initiative will help physicians, patient associations, industry, governments, and other stakeholders better face this epidemic in the near future.

BRAF mutations in non-small cell lung cancer: has finally Janus opened the door?

B-Raf mutations occur in about 1-2% of non-small cell lung cancers (NSCLC). These mutations generate a permanent activation of the mitogen activated protein kinase (MAPK) pathway, which promotes tumor growth and proliferation. In the present review, we discuss B-Raf mutation epidemiology, diagnostic methods to detect B-Raf mutations, the role of B-Raf as a driver mutation and a potential therapeutic target in NSCLC. The results of clinical trials involving B-Raf or MAPK pathway inhibitors for the treatment of NSCLC are also discussed. Clinical trials evaluating B-Raf inhibitors in BRAF mutated NSCLC patients have shown promising results, and larger prospective studies are warranted to validate these findings. Enrollment of these patients in clinical trials is an interesting strategy to offer a potentially more effective and less toxic targeted therapy.

Liquid Biopsy for Advanced Non-Small Cell Lung Cancer (NSCLC): A Statement Paper from the IASLC

ABSTRACT The isolation and analysis of circulating cell‐free tumor DNA in plasma is a powerful tool with considerable potential to improve clinical outcomes across multiple cancer types, including NSCLC. Assays of this nature that use blood as opposed to tumor samples are frequently referred to as liquid biopsies. An increasing number of innovative platforms have been recently developed that improve not only the fidelity of the molecular analysis but also the number of tests performed on a single specimen. Circulating tumor DNA assays for detection of both EGFR sensitizing and resistance mutations have already entered clinical practice and many other molecular tests — such as detection of resistance mutations for Anaplastic Lymphoma Kinase (ALK) receptor tyrosine kinase rearrangements — are likely to do so in the near future. Due to an abundance of new evidence, an appraisal was warranted to review strengths and weaknesses, to describe what is already in clinical practice and what has yet to be implemented, and to highlight areas in need of further investigation. A multidisciplinary panel of experts in the field of thoracic oncology with interest and expertise in liquid biopsy and molecular pathology was convened by the International Association for the Study of Lung Cancer to evaluate current available evidence with the aim of producing a set of recommendations for the use of liquid biopsy for molecular analysis in guiding the clinical management of advanced NSCLC patients as well as identifying unmet needs. In summary, the panel concluded that liquid biopsy approaches have significant potential to improve patient care, and immediate implementation in the clinic is justified in a number of therapeutic settings relevant to NSCLC.

Exosome-Based Detection of EGFR T790M in Plasma from Non–Small Cell Lung Cancer Patients

Purpose: About 60% of non–small cell lung cancer (NSCLC) patients develop resistance to targeted epidermal growth factor receptor (EGFR) inhibitor therapy through the EGFR T790M mutation. Patients with this mutation respond well to third-generation tyrosine kinase inhibitors, but obtaining a tissue biopsy to confirm the mutation poses risks and is often not feasible. Liquid biopsies using circulating free tumor DNA (cfDNA) have emerged as a noninvasive option to detect the mutation; however, sensitivity is low as many patients have too few detectable copies in circulation. Here, we have developed and validated a novel test that overcomes the limited abundance of the mutation by simultaneously capturing and interrogating exosomal RNA/DNA and cfDNA (exoNA) in a single step followed by a sensitive allele-specific qPCR. Experimental Design: ExoNA was extracted from the plasma of NSCLC patients with biopsy-confirmed T790M-positive (N = 102) and T790M-negative (N = 108) samples. The T790M mutation status was determined using an analytically validated allele-specific qPCR assay in a Clinical Laboratory Improvement Amendment laboratory. Results: Detection of the T790M mutation on exoNA achieved 92% sensitivity and 89% specificity using tumor biopsy results as gold standard. We also obtained high sensitivity (88%) in patients with intrathoracic disease (M0/M1a), for whom detection by liquid biopsy has been particularly challenging. Conclusions: The combination of exoRNA/DNA and cfDNA for T790M detection has higher sensitivity and specificity compared with historical cohorts using cfDNA alone. This could further help avoid unnecessary tumor biopsies for T790M mutation testing. Clin Cancer Res; 24(12); 2944–50. ©2018 AACR.

Immunotherapy for nonsmall-cell lung cancer

Systemic chemotherapy for nonsmall-cell lung cancer (NSCLC) has reached a plateau in effectiveness for several years and certainly biological therapy (approved antiangiogenic agents and tyrosine kinase inhibitors) has slightly improved survival; however, the mortality of NSCLC is very high and survival of metastatic disease is less than 2 years. Therefore, new approaches are required to improve current outcomes. Active-specific immunotherapy is an area of oncology that is rapidly expanding and delivering promising results such as asymptomatic prostate cancer with the use of sipuleucel-T. In the field of lung cancer, there are multiple vaccines focused on creating specific antitumor activity in NSCLC. Whole-cell vaccines like belagenpumatucel-L and antigen-specific vaccines like L-BLP25, TG4010, EGF vaccine and MAGE-A3 vaccines are undergoing phase III clinical trials after having demonstrated encouraging results in previous phase II trials with minimum toxicity. Hopefully, positive results will be revealed in the next few years, giving our lung cancer patients a new and more personalized therapy with better quality of life. The short review is indented to give an overview of the current data in the main studies of active immunotherapy for NSCLC.